A necessary silver lining?

In 2007, Kevin Fox put it simply – people are waiting too long for echocardiography1. Ms Kelly Victor, Lead  at Guy's and St Thomas' NHS Foundation Trust tells us why the status quo hasn't changed and how we must take forward the lessons learnt from COVID-19 to transform our services for the future.

This statement came on the back of a British Society of Echocardiography (BSE) survey which demonstrated two thirds of all patients were waiting longer than two weeks and one fifth longer than 18 weeks1. Unfortunately on a wider commissioning level, not much support and perhaps a little unfamiliarity resulted in Fox’s message falling on deaf ears. Fast forward 10 years and the coin had flipped. The NHS seven-day services report outlined clinical standards which proposed echocardiography diagnostics be almost immediate, with critically unwell patients reviewed within the hour, urgent requests performed within 12 hours and routine inpatients assessed within 24 hours if admitted as an emergency2. The gauntlet had been thrown and yet reviews of services, and internal and regional audits demonstrated inadequate capacity to address the challenge without the necessary provision of appropriate resource, infrastructure and workforce.

Now don’t get the wrong idea. No one wanted a pandemic. We all wish we never had to endure the experience; but the silver lining of COVID-19 is that a light has been shone on long term inherent problems solidly embedded within the foundation of the profession. With already well-established patient waits, a sieve-like workforce, dire digital technology and connectivity, COVID-19 has (? conveniently) amplified concerns. Current data suggests that the demand for echo activity continues to grow at 5.7% per annum with over 4% more patients waiting longer than 6 weeks compared to pre-COVID3. This problem is now such a sore thumb it has caught the attention of those of whom the attention was required, albeit some years ago.

The Richards’ report published this year mid COVID waves focussed on diagnostics, their recovery and renewal. The report acknowledged the need for radical investment and reformation of diagnostic services3. In the first instance it underlined the importance of ensuring we offer our patients procedures with the highest levels of safety. A given, and one which underpins our clinical practice ceaselessly and without question. It also encouraged new service models with ‘one stop bundle’ visits for patients, aligning clinical reviews with echo and other diagnostics tests such as ECGs, pacemaker checks, 24-hour ECG and BP monitors, and as such avoiding unnecessary risks associated with multi-trips to hospital. Although this is possible and idealistic, it is not always practical or feasible, particularly where patient care and communication systems vary across organisational and institutional boundaries.

Further recommendations honed in on the usefulness of triaging to separate acute and urgent, from elective diagnostics in order to help streamline productivity. For those considered urgent, ensuring that emergency and critical care departments have locally agreed pathways by which echocardiography can be performed in a clinically appropriate and timely manner was considered key. Taking this one step further and bearing in mind the high demands of echo on a national level, the British Society of Echocardiography (BSE) has been the first to react with positive change and valuable transformation. Embracing these recommendations, the BSE have devised clear, versatile and most importantly, useful triaging guides to assist in sorting the wheat from the chaff. These documents, three in the series, make things easy. They support triage as a vital component of the echo process, advocating that appropriate clinical time be dedicated to this chink in the chain in order to generate greater time and capacity for scanning patients who need it most. The guides are exactly that; guides which may vary depending on service provision or clinical situation with triaging differing between departments and regions contingent on skills set and workflow. The ultimate goal though is to use these guides in conjunction with local service models so as to ensure best practice. The knock on effect is that from the start patients can more effectively be filtered into the most appropriate pathway with their care organised either within acute care facilities or within the community.

Aside from triaging, Sir Richard’s recommendations also outline the development of diagnostic hubs outside of the hospital setting. These are targeted at again minimising acute hospitals visits but also offering a safer, ‘COVID-minimal’ testing environment and supporting the implementation of new delivery service models.

Moreover the report recommends data gathering in relation to staffing and workforce to enable planning for expansion. More echocardiographers should be trained the report says. But the big grey over-gained elephant in the room is that training an echocardiographer doesn’t happen overnight and that currently programmes providing this training take a minimum of two years. Of course there is the possibility of recruiting members of staff from other disciplines of cardiac science or perhaps radiography to promote ‘multitasking’ and emphasise appropriate skills mix. Maybe better engagement with our colleagues in emergency, acute and critical care medicine may assist in freeing up time for echocardiographers to contribute to the work of the community hubs. Perhaps we need to be considering the advent of artificial intelligence, it’s productivity, efficacy and reduced reliance on the workforce? Although many would argue we aren’t quite there yet. Which brings us back to new delivery models, different ways of working and thinking outside the box. COVID hatched the concept of level one TTE as the norm. This was aimed at reducing unnecessary exposure to patients with COVID when a more thorough scan was unlikely to change management. But where does this leave us now? Richard’s report prompts us to build on those pathways developed as part of the response to COVID-19. Does this present a concept to consider in our new delivery models and what are the risks? 

More widely the Richards’ review of diagnostic services highlighted immediate attention be directed to improving connectivity and digitalisation. There are many difference across regions of the UK, but the speed with which IT problems become solutions is not one of them. This is a slow process and one which hasn’t commenced since the Richard’s report was published. Ensuring IT connectivity and compatibility on a national level is an almost impossible task which many have been working on for years. It is clear that these solution would be effectual in combating some of the inefficiencies associated with duplication, sharing skills across sites and remote reporting and advice. Perhaps it is now our turn to throw down the gauntlet?

Clearly we have passed a point where major investment in the workforce and underlining infrastructure is necessary. Rightfully the Richards’ report also factors in the importance of clinical and managerial leadership on a local, regional, and national level, with the role out of development programmes to support network leadership. These groups will be driving change and supporting implementation across networks and given that we now have their attention it is up to us to ensure that the changes being made reflect the underlying  ethos and vision of the profession; ‘Promoting equal access to high quality echocardiography regardless of postcode.’  Rest assured that the BSE are fully engaged with this process and rather than being bystanders are actively pushing forward in support of their members with their own mission in mind; ‘to ensure that the echo community feels supported and enable to provide such services’. Now is the time for the change we needed. 

  1. Fox, K., 2007. Commissioning echocardiography: opportunities and risks to patients. British Journal of Cardiology, 14(4), pp.191-192
  2. NHS England. Seven Day Services Clinical Standards. 2017
  3. Richards, Mike (October 2020). Diagnostics: Recovery and Renewal. NHS England